An Observation Medicine Curriculum for Emergency Medicine Education

Audience and type of curriculum This curriculum, designed and implemented at the Ronald O. Perelman Department of Emergency Medicine at NYU Langone Health, primarily targets third- and fourth-year emergency medicine (EM) residents, and is an immersive observation medicine rotation that can be integrated into existing emergency medicine residency training. Length of curriculum The curriculum is designed for a dedicated rotation of two weeks for senior residents and can be expanded to 4 weeks. Introduction Observation medicine is an extension of emergency medicine and is increasingly playing a role in the delivery of acute healthcare, with over half of all observation units (OUs) in the nation being led by emergency medicine.1 Despite this, many emergency medicine residencies have yet to establish a formal observation medicine curriculum. In a 2002 study by Mace and Shah, only 10% of emergency medicine residencies had a dedicated observation medicine rotation, despite 85% of emergency medicine residency directors believing this was an important part of emergency medicine training.2 The first description of a model longitudinal observation medicine curriculum did not appear until 2016.3 In order to prepare our graduates for the evolving demands of the EM workplace, we must provide diverse educational experiences that train and showcase the expanding skill set of future emergency physicians. Educational Goals The primary goal of this observation medicine curriculum is to train current EM residents in short-term acute care beyond the initial ED visit. This entails caring for patients from the time of their arrival to the OU to the point when a final disposition from the OU is determined, be it inpatient admission or discharge to home. Educational Methods The educational strategies used in this curriculum include experiential learning through supervised direct patient care, independent learning based on prescribed literature, and didactic teaching. Research Methods Education content was evaluated by the learners through pre- and post-rotation surveys, as well as written attending evaluations describing the progress of the learners during the rotation. Results All residents reported increases in the confidence of their abilities to perform observation care. Discussion Observation medicine is an increasingly vital aspect of emergency medicine, but education in observation medicine has not developed in tandem with its implementation. A lack of observation medicine training represents a missed opportunity for each trainee to gain a robust understanding of the interface between inpatient and outpatient care, and how to arrive at the most appropriate disposition for ED patients. Considering the wide breadth of clinical conditions managed in OUs and the variability of OU management at various learning sites, the curriculum must be tailored to the specific unit to maximize effectiveness of the learning experience. Topics Observation medicine, curriculum, education, clinical rotation.


USER GUIDE
Residents will learn how to apply patient selection criteria to identify ED patients appropriate for OU care, perform initial OU arrival assessments, create an OU-appropriate management plan, and apply evidence-based, protocolized care to OU patients based on protocol-specific inclusion and exclusion criteria. Residents will also learn how to tailor ongoing patient care according to reassessments, select the appropriate disposition plan based on predetermined OU disposition goals, and coordinate post-discharge plans with a multi-disciplinary team of social workers, physical and occupational therapists, care managers and home health service liaisons to execute the disposition plan.
Residents will learn how to manage the following OU clinical conditions using evidence-based, protocolized care. The selected conditions were derived from a consensus decision by the authors based on our internally used observation protocols. Objective 2: Residents will learn the unique systems-based practice (SBP) differences of observation medicine relevant to emergency medicine.
The observation medicine rotation is structured to provide residents the opportunity to learn the key skills necessary to deliver the various stages of observation care. The resident will accept OU patient placement from the ED, complete the initial evaluation of new OU patients, and implement initial management steps such as protocol implementation and care coordination. Residents will learn ongoing management through periodic reassessments and actively managing the patient towards disposition endpoints. The resident will learn the nuances of effective disposition planning such as evaluating and resolving clinical and/or psychosocial discharge barriers through interdisciplinary collaboration with case managers, social workers, and home service liaisons. Residents will also learn distinguishing operational characteristics of observation units in the lectures entitled "Overview of Observation Medicine," "Systems-based Practices Relevant to Observation Medicine," and "Observation Documentation." Shift timing and length will depend on the logistics of each observation unit. For example, a larger unit with more robust provider staffing may allow for resident rotation at different shift times. In the presented curriculum, resident shifts are divided into two eight-hour shifts occurring over a twenty-four period (0800-1600; 1601-2359), each with unique workflows and complementary aspects of patient care. Actual shift duration and timing should be tailored to the individual observation unit staffing at the clinical site.
During the shift occurring from 0800-1600, the resident will be assigned to a teaching OU attending and participate in multidisciplinary handoff from the overnight team followed by morning rounds. The OU attending will identify which patients provide valuable clinical experiences and assign them to the resident.
During morning rounds, the resident will formulate a management plan that simultaneously addresses diagnostics and therapeutic strategies, coordinates care with consultants and allied health professionals, evaluates clinical progression, and develops an effective sign out at shift change. Specifically, residents will learn how to conduct efficient, team-based care during rounding. Residents will interface with nursing, social USER GUIDE Ty  work, pharmacy, and case management and will participate in team-based rounds to comprehensively address the needs of their assigned patients. Each resident will develop an understanding of the social determinants of health and how they impact disposition planning and outpatient care.
For the 1600-2359 shift, the resident will begin by attending sign out from the morning OU team. The resident will reassess these patients with the evening OU attending and progress the patient's management throughout the evening. During the remainder of the shift, the resident will mainly focus on accepting new patients from the ED. For each new patient, the resident will perform a verbal handoff on new patient placements from ED providers and summarize the intended observation care plan at the conclusion of the handoff conversation. They will formulate a complete management plan following the initial OU evaluation based on the verbal hand off from the ED, chart review, clinical evaluation, and discussion with the observation attending. Residents will use the electronic medical record (EMR) to document and place orders via order sets specific to observation care consistent with evidence-based clinical protocols. The resident will then execute the initial plan per protocol. The resident will engage in direct patient care supervised by a dedicated attending at all times.
Objective 3: Residents will learn how to complete required documentation for observation care.
The resident will learn how to complete the required documentation for observation care, such as the initial observation history and physical (H&P) with attention to OU anticipated care, the history of present illness (HPI), the complete past medical, surgical, social and family histories, a 10-point review of systems, code status documentation, medication reconciliation, and goals of care. The H&P will describe the intended care plan, the indication for observation, as well as clinical end points required for disposition.
Residents will learn to complete a daily progress note for patients following morning rounding that documents the need for ongoing observation care and relevant clinical events in a standard SOAP (subjective, objective, asessment, plan) note format. Residents will learn to complete an observation discharge narrative, which includes a summary of the observation hospital course, a final physical exam, and postdischarge plan, including follow-up information, discharge instructions, and discharge medication reconciliation.

Educational Strategies:
The resident will complete a rotation of at least two weeks and the rotation may be expanded to 4 weeks depending on the desired duration and intensity of the learning experience. After this introductory rotation, future OU shifts can be scheduled among ED shifts based on the interest of the residency program. The OU rotation should accommodate the number of residents that can be adequately supervised by the attending physician at a single time. Generally, this number will be 1-2 residents, but will also depend on the clinical complexity and size of the unit. All rotations should be coordinated by educational and operational leadership to ensure an effective learning experience. The resident will work five weekday 8-hour shifts each week. Residents should not be on back-up call during the rotation or have other service obligations in order to maximize the learning experience.
Prior to beginning the OU rotation, residents will be provided with literature to establish an initial knowledge base for the successful practice of observation medicine. The reading list represents a compilation of relevant peer-reviewed articles focusing on the management of common conditions seen in the OU, such as: chest pain, syncope, atrial fibrillation, transient ischemic attack (TIA), heart failure, infectious processes (ie, pneumonia, cellulitis, urinary tract infection), conditions associated with acute pain (ie, back pain, sickle cell crisis, headache), chronic obstructive pulmonary disease (COPD), asthma, alcohol withdrawal, and other conditions commonly managed in OUs. Suggested readings are included in this manuscript following the references. The resident should initially select relevant readings from this list throughout the rotation as they relate to patient care.
During the beginning of the rotation, the resident should manage patients that represent a relatively simple level of observation complexity (ie, chest pain, cellulitis, syncope, etc.), which will transition to more complex observation management (ie, heart failure, TIA, seizure, mild alcohol withdrawal, non-op fracture, complex psychosocial cases, a diagnostically ambiguous case, a clinically evolving patient, etc.) as the rotation progresses. The selection of appropriate patients should be at the discretion of the supervising attending.
Residents will receive regular, focused didactic teaching in the OU that is relevant to clinical conditions that they are managing. Each teaching will take approximately 10 to 15 minutes during the clinical shift and will review the evidence base for the protocolized OU care of a patient in the OU. based on relevance to patient care at that time. Additionally, the resident should conduct independent study and is expected to read relevant literature beyond shift times. Residents are also encouraged to participate in ongoing quality improvement projects in the OU. Residents may identify an area for future study and/or research in the OU. Of note, they will continue to attend the dedicated weekly EM didactic conference per their core curriculum and mandated by the Accreditation Council for Graduate Medical Education (ACGME) Emergency Medicine program requirements. 6,7 Residents will be evaluated on professionalism, communication skills, history, physical exam, ability to formulate and execute a plan of care, and ability to work as an integral part of a multidisciplinary team. Residents will be evaluated using the standard evaluation system currently in use at their residency program. OU attendings will also complete an evaluation of the resident at the end of each shift and provide direct formative verbal feedback to the resident. Resident evaluation content will be based on a selection of the EM Milestones identified by Wheatley et al, that have been determined by the authors as relevant to their observation medicine rotation. 5 At the end of the rotation, the rotation directors will review all evaluations and provide summative feedback of the resident to the residency program director.

Results and tips for successful implementation: Implementation
An online pre-rotation survey should be implemented to assess the resident's perceptions of his or her comfort practicing observation medicine, understanding of the role of observation medicine in acute care, and the role of observation medicine in the management of ED patients. This survey can be conducted both before and after the rotation to compare responses and evaluate efficacy of the rotation towards meeting the above objectives. As an example, this specific curriculum has been piloted with three senior EM residents thus far. All residents reported increases in the confidence of their abilities to perform observation care. De-identified survey results and comments from the residents are included in the appendix.
Considering the wide breadth of clinical conditions managed in OUs and the variability of OU management at various learning sites, the curriculum must be tailored to the specific unit to maximize effectiveness of the learning experience. It is key for representatives from both the educational and clinical operations teams to collaborate in the development and implementation of the OU experience, as well as having an ongoing process for collecting resident feedback of the rotation in the OU. This will allow optimization of the learning experience as the rotation matures and/or the OU evolves clinically.

Evaluation and Feedback:
In the development and optimization of this curriculum, seeking direct, face-to-face feedback from the residents was extremely helpful in collecting rich, detailed information about the rotation. The curriculum was modified based on learner feedback: the prepared materials for didactic teaching were expanded, the number of clinical preceptors were increased, the resident's role as an advanced practice provider (APP) supervisor was created, and the curriculum was adjusted. This also provided an opportunity for residents to increase their patient care load if they believe it to be useful towards reaching their educational goals. Pre-Rotation Written Question 1: What do you hope to gain from a rotation in observation medicine? Learner 1: Develop a better understanding of the role of the observation unit and the approach to a diagnostic work up of observation unit patients. Identify patient safety related issues in the observation unit and develop plan of action for improvement.

Appendices
Learner 2: Learn the treatment pathways and end goals for discharge.

Learner 3:
The ability to effectively assess and manage patients in an observation unit with a wide variety of diagnoses.
Post-Rotation Written Question 1: Do you feel that the observation medicine elective was useful for you, in the context of your emergency medicine training? Learner 1: Yes, this was a very useful rotation. Gave insight into the capabilities of the observation unit for further diagnostic testing and management of patients. Helped provide a better understanding of what it means to perform a cardiac rule out, will better enable me to make ER management decisions.

Post-Rotation Written Question 2:
Would you recommend the observation medicine elective to your fellow residents? Why or why not? Learner 1: Yes. Many residents will work in hospitals where they will be responsible for running observation units. This rotation could replace in part or all of the internal medicine rotation in residency as it teaches more relevant topics in the initial management of those admitted/observed in the hospital. Gives an important understanding of what happens to patients after placement in the hospital. Allows for senior residents to have a degree of personal responsibility for patients when running a side.
Learner 2: Yes if they want to see what obs is about. The staff and providers were great. Very welcoming. Very informative.
Learner 3: Yes, definitely. It is important to have an understanding of the management of patients beyond the ER. The rotation exposes one to internal medicine skills that we do not see in the ER, such as management of CHF, workup of angina, etc, that are important concepts for ER doctors to grasp. The rotation also allows for a chance for residents to work on formulating more of a differential diagnosis and management plan by being able to spend more time with a single patient and more time thinking about that patient than the time we have in the ER. Working in an observation unit is also required for many ER jobs and exposure in residency seems important if that is to be a part of one's career. Learner 2: The preceptor role was great.

Post-Rotation Written
Learner 3: I really enjoyed it. I enjoyed the mix of roles I was assigned, including taking care of patients already admitted to the observation unit, accepting new patients to the observation unit from the ER, and deciding on the workup and management plan for new observation unit patients. I also really enjoyed working one on one with the attending and hearing their thought process and seeing how they manage the patients, deciding who to send home, who to admit, who needs further workup and to what extent, etc. The lectures are also helpful and productive and I would recommend trying to have one every day on the rotation.